Psychoanalytic

approaches to
depression

Nancy McWilliams
• “I was recently told that every member of the work group who made
this call had some connection with a drug company. ”
• “ depression is the opposite of mourning; people who grieve
normally tend not to get depressed, even though they can be
overwhelmingly sad during the period that follows bereavement or
loss.”
• “The cognitive, affective, imaginal, and sensory processes that are so
striking in a clinical depression operate in a subtle, chronic,
organizing, self-perpetuating way in the psyches of those of us with
depressive personalities (Laughlin, 1956, 1967)”
• “ substantial proportion of psychotherapists are characterologically
depressive (Hyde, 2009).”
• “Blatt has studied the different internal experiences and different
therapeutic needs of people who formulate their depressive state as:
“I’m not good enough, I’m flawed, I’m self-indulgent, I’m evil” (the
“introjective” version): Narcissistic, self definition
• versus those whose subjective world feels like “I’m empty, I’m hungry,
I’m lonely, I need a connection” (the “anaclitic” version, from the
Greek word for “to lean on”).” Dependent, self-in-relationship
Predisposition
• Genetic: “Research with other mammals has identified patterns of
reaction to early maternal loss or rejection that look identical to
depression in humans (Panksepp, 2001).” (PANIC system)
• Experiential:
• “premature loss. In line with the classical theory that people who are either
overindulged or deprived become fixated at the infantile stage when this
happened, depressive individuals were initially understood as having been
weaned too soon or too abruptly, or as having suffered some other early
frustration that overwhelmed their capacities to adapt (see Fenichel, 1945).
The “oral” qualities of people with depressive characters influenced this
construction;”
• Discriminate between:
• “those who needed to be emotionally fed and those who needed to be asked why they
had not learned to cook”
• Consequence of Freud’s ideas (from internalized anger to why anger was
internalized):
• “trying to help their patients to identify things that had angered them so that the
pathological process could be reversed. It fell to later theorists to explain why a person
would have learned to turn angry reactions against the self and what functions would
be served by maintaining such a pattern.”

• “Depressive people are agonizingly aware of every sin they have committed, every
kindness they have neglected to extend, every selfish inclination that has crossed their
minds.”
• Feeling bad, or unworthy, makes them “good” people:
• “Because they aim hatred and criticism inward rather than outward, they are
usually generous, sensitive, and compassionate to a fault. Because they give
others the benefit of any doubt, and strive to preserve relationships at any
cost, they are natural appreciators of therapy. ”
Defensive mechanismstherapy
• Find the introjection:
• “one can practically hear the internalized object speaking. When a client says
something like, “It must be because I’m selfish,” a therapist can ask, “Who’s
saying that?” and be told, “My mother” (or father, or grandparent, or older
sibling, or whoever is the introjected critic).”
• Real person vs Experience and introjection of object (abandonment may
result in aggression and retaliation, like when splitting occurs)
• “A child may thus emerge from experiences of traumatic or premature loss
with an idealization of the lost object and a relegation of all
negative affect into his or her sense of self.”
• Love for the perceived aggression in the loved object: Idealization as
a fear of abandonment
• “If one emerges from painful separations believing that it is one’s badness
that drove the beloved objects away, one may try very hard to feel nothing
but positive affects toward those who are loved.”
• And to become a love-able object (by being “good”, at any cost)
The logics of defensive mechanisms of
depression
• “Turning against the self gains a reduction in anxiety, especially separation
anxiety (if one believes it is one’s anger and criticism that ensure
abandonment, one feels safer directing it against the self), and also
maintains a sense of power (if the badness inheres in me, I can change this
disturbing situation).”
• If caregiver is unreliable, one has 2 options:
• “Life sucks”(anaclitic) if they accept it, they may generalize that life is empty,
meaningless, and uninfluenceable, and they are left with a chronic sense of
incompleteness, emptiness, longing, futility, and existential despair.”
• “I suck” Introjective: “they deny that those they must depend upon are untrustworthy
(because they cannot bear living in fear), they may decide that the source of their
unhappiness lies within themselves, thereby preserving hope that self-improvement
can alter their circumstances”
Idealization’s logic: One is always less-than-ideal

“Self-perpetuating cycles of holding others in

excessively high regard, then feeling
diminished in comparison, then seeking
idealized* objects to compensate for the
diminution, feeling inferior to those objects,
and so on, are typical for depressive people.”
Early relational dynamics in
depression
• “The separation–individuation process eventuates in depressive
dynamics, Furman believed, only when the mother’s pain about her
child’s growth is so great that she either clings and induces guilt (“I’ll
be so lonely without you”)
= Separation is hurtful

• or pushes the child away defensively (“Why can’t you play by

yourself?!”
= Independence is needed, incapacity becomes self-definition
Example of familial patterns
• “Some depressive patients I have worked with appear to have been
the most emotionally astute person in their family of origin. Their
reactivity to upsetting situations that other family members handled
by denial got them branded “hypersensitive” or “overreactive,”
labels they continued to carry internally and to connect with their
general sense of inferiority.”

• They are more realistic, and express a normal feeling derived from an
abnormal situation
Perfect stated:
“ In a society where adults fail to make enough time to listen
sensitively to the concerns of children, where people move their
residence routinely, where family breakups are common, and where
painful emotions can be ignored because drugs will counteract them,
it is not surprising that our rates of youthful depression and suicide
have skyrocketed, that counter-depressive compulsions like
prescription drug abuse, obesity, and gambling are on the rise, that we
are seeing an explosion of popular movements in which the “lost child”
or the “child within” is rediscovered, and that self-help groups that
reduce feelings of isolation and fault are widely sought.”
Depressive Self
• “People with introjective depressive psychologies believe that at
bottom they are bad. They lament their greed, their selfishness, their
competition, their vanity, their pride, their anger, their envy, their lust.
They consider all these normal aspects of experience to be
perverse and dangerous. They worry that they are inherently
destructive. These anxieties can take a more or less oral tone (“I’m
afraid my hunger will destroy others”), or an anal-level one (“My
defiance and sadism are dangerous”), or a more oedipal dimension
(“My wishes to compete for and win love are evil”).”
 More common in women: Identity revisited
• “the primary caregiver is female. Male children consequently attain a sense of
gender identity from being different from the mother, and females derive it
from identification with her. An outcome of this imbalance in early parenting is
that men use introjection less, as their masculinity is confirmed by separation
rather than by fusion, and women use it more, because their
sense of femaleness comes from connection. When feeling
internally empty, men may be more likely to use denial and to behave
counterdependently than to experience themselves anaclitically as needy and
longing.”
In therapy:
• “easy to love. They attach quickly, ascribe benevolence to the
therapist’s aims even when fearing criticism, are moved by empathic
responsiveness, work hard to be “good” in the patient role,
and appreciate bits of insight as if they were morsels of life-sustaining
food. They tend to idealize the clinician (as morally good, in
contrast to their subjective badness, or as filling their internal emptiness), but
not in the emotionally unconnected way typical of more narcissistically
structured patients. Depressive people are highly respectful of the therapist’s
status as a separate, real, and caring human being, and they try hard not
to be burdensome.”
 Countertransference

• “Countertransference with depressive individuals runs the gamut from

benign affection to omnipotent rescue fantasies, depending
upon the severity of the depressive issues. Such reactions constitute a
complementary countertransference (Racker, 1968); the therapeutic
fantasy is that one can be God, or the “Good Mother,” or the sensitive,
accepting parent that the client never had. These longings can be
understood as a response to the patient’s unconscious belief that the cure
for depressive dynamics is unconditional love and total understanding. ”
• OR “One can feel incompetent, blundering, damaging, “not
good enough” (the introjective elements) or hopeless, incompetent,
demoralized, and futile (the anaclitic elements). Depressive attitudes are
contagious.” (concurrent countertransference)
• “It is critical with depressive patients of both types to explore and
interpret their reactions to separation, even to the separation
of brief silence from the therapist. (Long silences should be avoided*;
they arouse the feelings of being uninteresting, valueless, adrift, hopeless.) ”
• But…
• “But what depressive people really need is not uninterrupted care. What they need
is the experience that the therapist returns after a
separation**. They need to know that their anger at being
abandoned did not destroy the relationship and that their
hunger did not permanently alienate the therapist. One
cannot learn these lessons without enduring a loss [in the
relationship] in the first place.”